Morbidity and Mortality Weekly Report

Weekly / Vol. 73 / No. 13 April 4, 2024

Surveillance To Track Progress Toward Polio Eradication —

Worldwide, 2022–2023
Nishant Kishore, PhD1; Elizabeth Krow-Lucal, PhD2; Ousmane M. Diop, PhD2; Jaume Jorba, PhD3; Tigran Avagnan, MSc4;
Varja Grabovac, MSc4; Anfumbom K.W. Kfutwah, PhD5; Ticha Johnson, MD5; Sudhir Joshi, MPH6; Lucky Sangal, MD6; Salmaan Sharif, PhD7;
Ashraf Wahdan, MD7; Graham F. Tallis, MPH2; Stephanie D. Kovacs, PhD1

Abstract cases has declined by >99.9%, and WPV serotypes 2 and 3 have
The reliable and timely detection of poliovirus cases through been declared eradicated (1). By the end of 2023, WPV type 1
surveillance for acute flaccid paralysis (AFP), supplemented (WPV1) transmission remained endemic only in Afghanistan
by environmental surveillance of sewage samples, is a critical and Pakistan (2,3). However, during 2021–2022, Malawi and
component of the polio eradication program. Since 1988, Mozambique reported nine WPV1 cases caused by a virus
the number of polio cases caused by wild poliovirus (WPV) genetically linked to cases from Pakistan (last paralysis onset
has declined by >99.9%, and eradication of WPV serotypes 2 date on August 10, 2022) (4,5). In areas with low polio vac-
and 3 has been certified; only serotype 1 (WPV1) continues cination coverage, prolonged circulation of vaccine-derived
to circulate, and transmission remains endemic in Afghanistan polioviruses (VDPV) can result in their reversion to neuro-
and Pakistan. This surveillance update evaluated indicators virulence. Infection with these circulating VDPVs (cVDPVs)
from AFP surveillance, environmental surveillance for polio- can cause paralysis and polio outbreaks; cVDPV outbreaks
viruses, and Global Polio Laboratory Network performance have been detected in 42 countries (6).
data provided by 28 priority countries for the program during Polioviruses are detected primarily through surveillance for
2022–2023. No WPV1 cases have been detected outside of acute flaccid paralysis (AFP), confirmed through stool speci-
Afghanistan and Pakistan since August 2022, when an impor- men testing. Environmental surveillance (ES), the systematic
tation into Malawi and Mozambique resulted in an outbreak sampling of sewage and testing for the presence of poliovirus,
during 2021–2022. During 2022–2023, among 28 priority supplements AFP surveillance by detecting poliovirus circu-
countries, 20 (71.4%) met national AFP surveillance indicator lation independent of confirmed paralytic polio cases. This
targets, and the number of environmental surveillance sites
increased. However, low national rates of reported AFP cases
in priority countries in 2023 might have resulted from surveil- INSIDE
lance reporting lags; substantial national and subnational AFP 286 Federal Retail Pharmacy Program Contributions to
surveillance gaps persist. Maintaining high-quality surveillance Bivalent mRNA COVID-19 Vaccinations Across
is critical to achieving the goal of global polio eradication. Sociodemographic Characteristics — United States,
Monitoring surveillance indicators is important to identify- September 1, 2022–September 30, 2023
ing gaps and guiding surveillance-strengthening activities, 291 Notice to Readers: Change in Publication Date
particularly in countries at high risk for poliovirus circulation. of QuickStats
293 QuickStats
Introduction
Since the Global Polio Eradication Initiative (GPEI) was
Continuing Education examination available at
established in 1988, the number of wild poliovirus (WPV) https://www.cdc.gov/mmwr/mmwr_continuingEducation.html

U.S. Department of Health and Human Services

Centers for Disease Control and Prevention
 Morbidity and Mortality Weekly Report

report updates previous reports (7,8) to describe polio surveil- Acute Flaccid Paralysis and Environmental Surveillance
lance performance during 2022–2023 in 28 priority countries AFP surveillance quality was assessed for 28 priority coun-
(i.e., those deemed to be at high risk for poliovirus transmis- tries both at the national level and at 511 first administrative
sion because of ongoing surveillance gaps and vulnerability to subnational (i.e., state or province) level using two performance
poliovirus circulation).* indicators: 1) the nonpolio AFP (NPAFP) rate† (an NPAFP
rate of two or more NPAFP cases per 100,000 persons aged
Methods <15 years indicates AFP surveillance is sufficiently sensitive to
Data Sources detect circulating poliovirus), and 2) stool adequacy (two stools
Data analyzed in this study were obtained from 1) the World collected within 14 days of paralysis onset, ≥24 hours apart, and
Health Organization (WHO) Polio Information System as of received by a WHO-accredited laboratory via reverse cold chain
March 11, 2024, and 2) the Global Polio Laboratory Network and in good condition)§ with a target of ≥80% adequate stool
(GPLN) as of January 31, 2024. These data are the property of specimens collected from AFP patients. ES site sensitivity to
the individual countries, and data access was provided through detect poliovirus is assessed by the annual enterovirus isolation
the GPEI Data Sharing Agreement. rate, defined as the percentage of specimens with enterovirus
detected, with a target of ≥50%.

* Priority countries were included if they were deemed at high risk for poliovirus
† The number of NPAFP cases per 100,000 children aged <15 years per year.
transmission in a country risk assessment exercise because of ongoing gaps in
surveillance and vulnerability to poliovirus circulation, as described in the NPAFP cases are cases of AFP determined not to be polio upon further case
WHO Global Polio Surveillance Action Plan, 2022–2024 (https:// investigation and stool testing. The threshold of two or more NPAFP cases
polioeradication.org/wp-content/uploads/2022/05/GPSAP-2022-2024-EN. indicating that AFP surveillance is sufficiently sensitive to detect circulating
pdf ). The priority countries are updated every year. The 2023 priority countries polio is based on a background rate of AFP due to etiologies other than
include the following: African Region (21): Angola, Botswana, Burkina Faso, polioviruses. The NPAFP rate is difficult to interpret when the population aged
Burundi, Cameroon, Central African Republic, Chad, Democratic Republic <15 years is below 100,000.
§ Two stool specimens that are collected from patients with AFP within 14 days
of the Congo, Equatorial Guinea, Ethiopia, Kenya, Madagascar, Malawi, Mali,
Mozambique, Niger, Nigeria, South Sudan, Tanzania, Zambia, and Zimbabwe; of paralysis onset, ≥24 hours apart, and received in good condition (i.e., without
Eastern Mediterranean Region (five): Afghanistan, Pakistan, Somalia, Sudan, leakage or desiccation) by a WHO-accredited laboratory via reverse cold chain
and Yemen; South-East Asia Region (one): Indonesia; Western Pacific Region (a transportation and storage method designed to keep samples at recommended
(one): Papua New Guinea. temperatures from collection through arrival at the laboratory).

The MMWR series of publications is published by the Office of Science, Centers for Disease Control and Prevention (CDC), U.S. Department of Health and Human
Services, Atlanta, GA 30329-4027.
Suggested citation: [Author names; first three, then et al., if more than six.] [Report title]. MMWR Morb Mortal Wkly Rep 2024;73:[inclusive page numbers].
Centers for Disease Control and Prevention
Mandy K. Cohen, MD, MPH, Director
Debra Houry, MD, MPH, Chief Medical Officer and Deputy Director for Program and Science
Samuel F. Posner, PhD, Director, Office of Science

MMWR Editorial and Production Staff (Weekly)

Charlotte K. Kent, PhD, MPH, Editor in Chief Phyllis H. King, Symone Hairston, MPH,
Rachel Gorwitz, MD, MPH, Acting Executive Editor Acting Lead Health Communication Specialist Acting Lead Health Communication Specialist
Jacqueline Gindler, MD, Editor Alexander J. Gottardy, Maureen A. Leahy, Kiana Cohen, MPH,
Paul Z. Siegel, MD, MPH, Associate Editor Stephen R. Spriggs, Armina Velarde, Tong Yang, Leslie Hamlin, Lowery Johnson,
Mary Dott, MD, MPH, Online Editor Visual Information Specialists Health Communication Specialists
Terisa F. Rutledge, Managing Editor Quang M. Doan, MBA, Dewin Jimenez, Will Yang, MA,
Teresa M. Hood, MS, Lead Technical Writer-Editor Terraye M. Starr, Moua Yang, Visual Information Specialists
Glenn Damon, Jacqueline Farley, MS, Information Technology Specialists
Tiana Garrett, PhD, MPH, Ashley Morici,
Stacy Simon, MA, Morgan Thompson,
Suzanne Webb, PhD, MA,
Technical Writer-Editors

MMWR Editorial Board

Timothy F. Jones, MD, Chairman
Matthew L. Boulton, MD, MPH David W. Fleming, MD Patrick L. Remington, MD, MPH
Carolyn Brooks, ScD, MA William E. Halperin, MD, DrPH, MPH Carlos Roig, MS, MA
Virginia A. Caine, MD Jewel Mullen, MD, MPH, MPA William Schaffner, MD
Jonathan E. Fielding, MD, MPH, MBA Jeff Niederdeppe, PhD Morgan Bobb Swanson, MD, PhD
Patricia Quinlisk, MD, MPH

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 Morbidity and Mortality Weekly Report

Global Polio Laboratory Network across the entire region met both indicator targets in 2022,
The GPLN consists of 144 WHO-accredited laboratories in the percentage declined to 80.4% in 2023. As of the reporting
the six WHO regions, monitored through a standardized qual- date, 11 WPV1 and 15 cVDPV2 cases were reported in 2023
ity assurance program of annual onsite audits and proficiency compared with 22 and 166, respectively, in 2022.
testing (9). All 144 GPLN laboratories are responsible for South-East Asia Region. The WHO South-East Asia
isolating polioviruses; 134 conduct intratypic differentiation Region (SEAR) includes one priority country (Indonesia).
to identify WPV, VDPV, and Sabin (oral poliovirus vaccine) At the national level, the NPAFP rate increased from 3.5 to
polioviruses; 28 laboratories conduct genomic sequencing. 5.8 cases per 100,000; the percentage of stool samples that were
adequate did not meet the indicator in either 2022 or 2023.
Analysis Indonesia reported six cVDPV2 cases in 2023 compared with
R software (version 4.3.1; R Foundation) was used to one case in 2022.
conduct all analyses. All administrative boundaries, as well as Western Pacific Region. The WHO Western Pacific Region
the disputed borders, and the lakes within the disputed areas includes one priority country (Papua New Guinea); neither
dataset were sourced from the WHO and GPEI administra- national surveillance indicator target was met during this
tive boundary project (https://polioboundaries-who.hub. assessment period. No poliovirus was detected in Papua New
arcgis.com/). This activity was reviewed by CDC, deemed not Guinea during 2022–2023.
research, and was conducted consistent with applicable federal
law and CDC policy.¶ Environmental Surveillance
In 2023, 27 (96.4%) of the 28 priority countries** had at
Results least one ES site reporting. In priority countries in AFR, the
number of ES sites decreased 2%, from 386 in 2022 to 378
Acute Flaccid Paralysis
in 2023; however, the proportion of sites meeting the entero-
Surveillance indicators and detected cases were assessed in virus sensitivity target increased 41%, from 41.7% to 58.8%.
28 priority countries during 2022–2023 (Table 1). Priority In 2022 and 2023, ≥80% of sites in 18 and 19 countries,
countries include 21 in the African region, five in the Eastern respectively, met the ≥50% enterovirus isolation rate target.
Mediterranean region, and one each in the South-East Asia The number of ES sites in EMR increased 134%, from 244
and Western Pacific regions. in 2022 to 571 in 2023; this increase was driven by Pakistan,
African Region. Among the 21 priority countries in the which added 308 new ES sites in 2023. However, only 133
WHO African Region (AFR), 18 (85.7%) met both surveil- (26.7%) of all ES sites in Pakistan reported five or more col-
lance indicator targets nationally in 2023, compared with 17 lections in 2023. In Somalia and Sudan, the proportion of
(81%) in 2022. In 2023, all countries met the NPAFP rate sites meeting the sensitivity indicator declined from 100% to
target of two or more NPAFP cases per 100,000 persons aged 35.3% and from 85.7% to 60%, respectively.
<15 years. In Indonesia, the only priority country evaluated in SEAR,
In 2022 and 2023, 70.8% of 356 and 75.8% of 355 subna- the number of ES sites decreased from 16 in 2022 to 12 in
tional regions, respectively, met both targets. Eleven countries 2023. However, the proportion of sites that met the sensitiv-
reported that ≥80% of subnational regions met both indicators ity indicator increased from 25% in 2022 to 45.5% in 2023.
in 2023 (Figure) compared with nine countries in 2022.
Eight WPV1 cases were detected in 2022 linked to one Global Polio Laboratory Network
reported imported WPV1 case with onset in 2021; no WPV1 In 2023, the GPLN tested 233,437 stool specimens collected
cases were reported in 2023. The number of VDPV cases from patients with AFP (Table 2). All WHO regions except
decreased from 690 (192 cVDPV type 1 [cVDPV1] and the Region of the Americas met the timeliness target for viral
498 cVDPV type 2 [cVDPV2]) in 2022 to 471 (133 cVDPV1 isolation (results reported for ≥80% of specimens ≤14 days after
and 338 cVDPV2) in 2023. receipt of specimen). All regions met the timeliness indicator
Eastern Mediterranean Region. Among the five priority for reporting (results reported for ≥80% of specimens within
countries in the WHO Eastern Mediterranean Region (EMR), 7 days of receipt of isolates in the laboratory).
all met both national surveillance indicator targets in 2022, and In genetic sequencing performed during 2022–2023, the
four met targets in 2023. Whereas 87.4% of subnational areas South Asia genotype was the only circulating WPV1 isolated

¶ 45 C.F.R. part 46.102(l)(2), 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d); 5 U.S.C.
Sect. 552a; 44 U.S.C. Sect. 3501 et seq. ** No ES sites were reported from Papua New Guinea during 2022–2023.

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 Morbidity and Mortality Weekly Report

TABLE 1. National and subnational acute flaccid paralysis surveillance performance indicators and number of confirmed wild poliovirus and
circulating vaccine-derived poliovirus cases, by country — 28 priority countries, World Health Organization African, Eastern Mediterranean,
South-East Asia, and Western Pacific regions, 2022 and 2023*
% No. of confirmed cases
Subnational Regional/National Subnational areas
No. of Regional/ areas with NPAFP no. of AFP cases with ≥80% Subnational areas
Year/WHO region/ AFP cases National rate of two or with adequate adequate stool meeting both WPV cVDPV cases
Country (all ages) NPAFP rate† more cases§ stool specimens¶ specimens§,¶ indicators§,¶,** cases (type 1, type 2)††
2022
AFR (N = 21) 27,786 7.1 N/A 90.6 N/A N/A 8 690 (192, 498)
Angola 386 2.4 66.7 89.6 83.3 75.9 —§§ —
Botswana 32 3.5 45.8 78.1 33.3 24.5 — —
Burkina Faso 1,260 12.4 100.0 93.0 100.0 100.0 — —
Burundi 128 2.1 50.0 87.5 77.8 37.1 — 1 (0, 1)
Cameroon 852 7.1 100.0 81.9 60.0 62.1 — 3 (0, 3)
CAR 215 7.6 100.0 86.0 57.1 64.9 — 6 (0, 6)
Chad 1,254 14.3 100.0 82.1 52.2 52.4 — 44 (0, 44)
DRC 4,577 8.6 100.0 85.8 61.5 61.0 — 523 (150, 373)
Equatorial Guinea 388 6.7 100.0 88.9 100.0 100.0 — —
Ethiopia 1,606 3.2 90.9 93.0 90.9 92.8 — 1 (0, 1)
Kenya 653 3.2 85.1 87.0 76.6 70.0 — —
Madagascar 646 5.4 100.0 95.2 100.0 100.0 — 16 (16, 0)
Malawi 481 5.1 100.0 71.7 25.0 0.1 — 4 (4, 0)
Mali 562 5.3 100.0 87.2 90.9 99.5 — 2 (0, 2)
Mozambique 929 5.9 100.0 74.5 18.2 15.7 8 26 (22, 4)
Niger 991 7.6 100.0 87.8 75.0 74.3 — 16 (0, 16)
Nigeria 10,247 10.8 100.0 96.7 100.0 100.0 — 48 (0, 48)
South Sudan 557 11.4 100.0 93.9 100.0 100.0 — —
Tanzania 1,283 4.5 93.5 98.1 100.0 98.6 — —
Zambia 390 4.3 100.0 65.9 10.0 18.7 — —
Zimbabwe 349 5.1 100.0 90.8 90.0 90.6 — —
EMR (N = 5) 26,786 18.3 N/A 87.0 N/A N/A 22 166 (0, 166)
Afghanistan 5,370 30.2 100.0 94.4 100.0 100.0 2 —
Pakistan 19,033 22.0 85.7 84.9 100.0 100.0 20 —
Somalia 356 4.2 90.5 97.2 95.2 96.7 — 5 (0, 5)
Sudan 650 3.4 100.0 97.1 94.4 98.1 — 1 (0, 1)
Yemen 1,377 9.1 100.0 81.0 60.9 59.7 — 160 (0, 160)
SEAR (N = 1) 2,412 3.5 N/A 73.7 N/A N/A — 1 (0, 1)
Indonesia 2,412 3.5 73.5 73.7 26.5 20.1 — 1 (0, 1)
WPR (N = 1) 63 1.8 N/A 65.1 N/A N/A — —
Papua New Guinea 63 1.8 22.7 65.1 40.9 7.5 — —
2023
AFR (N = 21) 31,325 7.8 N/A 91.4 N/A N/A — 492 (133, 359)
Angola 482 2.7 77.8 84.6 72.2 77.9 — —
Botswana 42 3.7 45.8 73.8 37.5 29.3 — —
Burkina Faso 1,126 10.8 100.0 94.3 100.0 100.0 — 2 (0, 2)
Burundi 174 2.7 72.2 82.2 61.1 35.4 — 1 (0, 1)
Cameroon 855 7.0 100.0 87.6 80.0 87.9 — —
CAR 209 6.8 100.0 80.9 57.1 63.3 — 15 (0, 15)
Chad 1,497 16.6 95.7 87.4 78.3 84.6 — 55 (0, 55)
DRC 4,674 9.1 100.0 83.3 69.2 69.1 — 223 (105, 118)
Equatorial Guinea 581 8.8 100.0 85.4 87.5 91.2 — 47 (0, 47)
Ethiopia 1,449 2.8 90.9 94.5 90.9 99.2 — —
Kenya 693 3.2 83.0 88.0 70.2 64.3 — 8 (0, 8)
Madagascar 1,424 11.0 100.0 90.6 100.0 100.0 — 24 (24, 0)
Malawi 554 5.9 100.0 90.1 100.0 100.0 — —
Mali 991 8.8 100.0 91.9 90.9 99.1 — 16 (0, 16)
Mozambique 676 4.2 100.0 81.5 72.7 77.7 — 5 (4, 1)
Niger 752 5.6 100.0 76.9 50.0 23.9 — 2 (0, 2)
Nigeria 12,020 12.4 100.0 97.3 100.0 100.0 — 87 (0, 87)
South Sudan 554 11.1 100.0 95.7 100.0 100.0 — 2 (0, 2)
Tanzania 1,551 5.2 100.0 97.0 100.0 100.0 — 3 (0, 3)
Zambia 682 6.6 100.0 79.2 70.0 71.0 — 1 (0, 1)
Zimbabwe 339 4.7 100.0 87.9 80.0 82.0 — 1 (0, 1)
See table footnotes the next page.

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 Morbidity and Mortality Weekly Report

TABLE 1. (Continued) National and subnational acute flaccid paralysis surveillance performance indicators and number of confirmed wild
poliovirus and circulating vaccine-derived poliovirus cases, by country — 28 priority countries, World Health Organization African, Eastern
Mediterranean, South-East Asia, and Western Pacific regions, 2022 and 2023*
% No. of confirmed cases
Subnational Regional/ national Subnational areas
No. of Regional/ areas with NPAFP no. of AFP cases with ≥80% Subnational areas
Year/WHO region/ AFP cases National rate of two or with adequate adequate stool meeting both WPV cVDPV cases
Country (all ages) NPAFP rate† more cases§ stool specimens¶ specimens§,¶ indicators§,¶,** cases§§ (type 1, type 2)††
EMR (N = 5) 27,794 18.6 N/A 86.1 N/A N/A 11 15 (0, 15)
Afghanistan 5,852 32.3 100.0 94.0 100.0 100.0 5 —
Pakistan 19,714 22.3 85.7 83.9 85.7 98.7 6 —
Somalia 424 4.9 100.0 93.4 95.0 98.4 — 8 (0, 8)
Sudan 473 2.0 77.8 75.3 44.4 10.7 — —
Yemen 1,331 9.4 100.0 84.2 87.0 83.1 — 7 (0, 7)
SEAR (N = 1) 4,362 5.8 N/A 73.3 N/A N/A — 6 (0, 6)
Indonesia 4,362 5.8 79.4 73.3 20.6 20.3 — 6 (0, 6)
WPR (N = 1) 61 1.3 N/A 54.1 N/A N/A — —
Papua New Guinea 61 1.3 18.2 54.1 22.7 4.4 — —
Abbreviations: AFP = acute flaccid paralysis; AFR = African Region; CAR = Central African Republic; cVDPV = circulating vaccine-derived poliovirus; DRC = Democratic
Republic of the Congo; EMR = Eastern Mediterranean Region; N/A = not applicable; NPAFP = nonpolio acute flaccid paralysis; SEAR = South-East Asia Region;
WHO = World Health Organization; WPR = Western Pacific Region; WPV = wild poliovirus.
* Data as of March 11, 2024.
† Per 100,000 persons aged <15 years per year.
§ For all subnational areas regardless of population size.
¶ Surveillance targets are two or more NPAFP cases per 100,000 persons aged <15 years per year and ≥80% of persons with AFP having two stool specimens collected
within 14 days of paralysis onset and ≥24 hours apart and received in good condition (i.e., without leakage or desiccation) by a WHO-accredited laboratory via
reverse cold chain (storing and transporting samples at recommended temperatures from the point of collection to the laboratory).
** Percentage of the country’s population aged <15 years living in subnational areas that met both surveillance indicators (NPAFP rates of two or more per 100,000 persons
aged <15 years per year and ≥80% of AFP cases with adequate specimens).
†† https://polioeradication.org/wp-content/uploads/2016/09/Reporting-and-Classification-of-VDPVs_Aug2016_EN.pdf
§§ Dashes indicate that no confirmed cases were found.

from 42 persons with AFP (30 in 2022 and 12 in 2023) Discussion

in the two countries with endemic WPV1 transmission Among 28 polio priority countries assessed during the
(Afghanistan and Pakistan) (2,3) and one person with AFP 2022–2023 surveillance evaluation period, 20 (71.4%) met
from Mozambique (5). In Pakistan, all 2022–2023 isolates were national AFP surveillance targets, and the total number of
related to the YB3A genetic cluster (i.e., groups of polioviruses ES sites increased. Although the overall number of ES sites
sharing ≥95% sequence identity in the region coding the viral increased in EMR, Somalia and Sudan reported large decreases
capsid protein VP1) except three isolates in 2023, which were in the proportion of sites meeting the 50% enterovirus detec-
related to genetic cluster YB3C. In Afghanistan, all isolates tion surveillance sensitivity indicator. The national NPAFP rate
were related to the YB3A genetic cluster. In Mozambique, eight decreased in 14 of the 28 priority countries in 2023; Papua New
WPV1 polio cases in 2022 were linked to the YC2 genetic Guinea did not meet the NPAFP target. Similarly, the percent-
cluster; no new WPV1 cases were detected in 2023. During ages of adequate stool samples from persons with AFP declined
the reporting period, cluster YB3A was detected in ES samples in 15 (53.5%) priority countries; Botswana, Indonesia, Niger,
from Afghanistan and clusters YB3A and YB3C in ES samples Papua New Guinea, and Sudan did not reach target indicators.
from Pakistan; five ES detections (four in Pakistan and one The detection of imported WPV1 in Malawi and
in Afghanistan) were orphan viruses (i.e., isolates with ≥1.5% Mozambique in 2021–2022 highlights the importance of
nucleotide divergence of the VP1-coding region from known outbreak response in strengthening surveillance systems (4,5).
isolates), indicating that virus circulation was prolonged. Response to the 2021 WPV1 importation included Malawi,
In the 28 priority countries during 2022–2023, viruses Mozambique, Tanzania, Zambia, and Zimbabwe. All response
from 37 cVDPV emergence groups (those not linked to any countries met the NPAFP rate target in 2023. Zambia reported
other outbreak, including seven cVDPV1 and 30 cVDPV2 a stool adequacy rate just below the target; however, the pro-
emergence groups) were isolated from 1,320 AFP patients and portion of AFP cases with adequate specimens increased from
607 ES samples. The number of cVDPV1 emergence groups 65.9% in 2022 to 79.2% in 2023. All subnational areas in
decreased from seven in 2022 to four in 2023. The number Mozambique met the NPAFP target in 2022 and 2023, and the
of cVDPV2 emergence groups increased from 18 in 2022 to proportion of subnational regions meeting the stool adequacy
22 emergence groups in 2023. target improved from 18.2% to 72.7% in 2023.
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 Morbidity and Mortality Weekly Report

FIGURE. Combined performance indicators for the quality of acute flaccid paralysis surveillance*,† in subnational areas of 28 priority
countries§,¶ — World Health Organization African, Eastern Mediterranean, South-East Asia, and Western Pacific regions, 2023**

Population aged <15 years below 100,000

NPAFP rate of two or more cases and
specimen adequacy ≥80%
NPAFP rate of two or more cases and specimen adequacy <80%
or NPAFP rate of less than two cases and specimen adequacy ≥80%
NPAFP rate of less than two cases and specimen adequacy <80%
Data not available
Not applicable

Abbreviations: AFP = acute flaccid paralysis; NPAFP = nonpolio acute flaccid paralysis; WHO = World Health Organization.
* The number of NPAFP cases per 100,000 children aged <15 years per year. NPAFP cases are cases of AFP determined not to be polio upon further case investigation
and stool testing. The threshold of two or more NPAFP cases indicating that AFP surveillance is sufficiently sensitive to detect circulating polio is based on a
background rate of AFP due to etiologies other than polioviruses.
† Surveillance targets are two or more NPAFP cases per 100,000 persons aged <15 years per year and ≥80% of persons with AFP having two stool specimens collected
within 14 days of paralysis onset, ≥24 hours apart, and received in good condition (i.e., without leakage or desiccation) by a WHO-accredited laboratory via reverse
cold chain (storing and transporting samples at recommended temperatures from the point of collection to the laboratory).
§ The 2023 priority countries include the following: African Region (21): Angola, Botswana, Burkina Faso, Burundi, Cameroon, Central African Republic, Chad, Democratic
Republic of the Congo, Ethiopia, Equatorial Guinea, Kenya, Madagascar, Malawi, Mali, Mozambique, Niger, Nigeria, South Sudan, Tanzania, Zambia, and Zimbabwe;
Eastern Mediterranean Region (five): Afghanistan, Pakistan, Somalia, Sudan, and Yemen; South-East Asia Region (one): Indonesia; Western Pacific Region (one):
Papua New Guinea.
¶ NPAFP rate is difficult to interpret when the population aged <15 years is below 100,000.
** Dotted and dashed lines on maps represent approximate border lines for which there might not yet be full agreement.

Limitations available for analysis. Thus, whereas decreases in overall case

The findings in this report are subject to at least three limita- numbers are encouraging, these trends might be affected by
tions. First, metrics collected for this analysis can take weeks incomplete data resulting from surveillance lags. Second, per-
or months to be uploaded to the surveillance system and be formance measures reported at regional and national levels can

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 Morbidity and Mortality Weekly Report

TABLE 2. Number of poliovirus isolates from stool specimens of persons with acute flaccid paralysis and timing of results, by World Health
Organization region — worldwide, 2022 and 2023*,†
No. of poliovirus isolates % ITD results
% of on time††
WHO region/ No. of poliovirus isolation Within 7 days of Within 60 days of
Year specimens Wild§ Sabin¶ cVDPV** test results receipt at laboratory§§ paralysis onset¶¶
Africa
2022 53,961 8 3,065 453 86 85 83
2023 72,543 0 397 538 88 92 94
Americas
2022 1,858 0 7 2 74 100 67
2023 1,826 0 2 0 72 100 100
Eastern Mediterranean
2022 57,364 32 1,331 277 75 88 82
2023 76,322 19 2,033 9 92 100 79
European
2022 2,980 0 22 2 79 91 91
2023 2,910 0 33 4 83 97 92
South-East Asia
2022 67,118 0 1,067 2 96 98 93
2023 67,100 0 783 10 94 95 96
Western Pacific
2022 10,664 0 32 0 98 100 100
2023 12,736 0 140 0 97 99 90
Total††
2022* 193,945 40 5,524 736 87 88 85
2023** 233,437 19 3,388 561 91 97 86
Abbreviations: AFP = acute flaccid paralysis; cVDPV = circulating vaccine-derived poliovirus; ITD = intratypic differentiation; VDPV = vaccine-derived poliovirus;
VP1 = poliovirus capsid viral protein 1; WHO = World Health Organization; WPV = wild poliovirus.
* Data for 2023 received from WHO regions during January 15–31, 2024.
† Data for 2022 current as of January 31, 2023.
§ Number of AFP cases with WPV isolates.
¶ Either 1) concordant Sabin-like results in ITD test and VDPV screening, or 2) ≤1% VP1 nucleotide sequence difference compared with Sabin vaccine virus (≤0.6%
for type 2).
** For poliovirus types 1 and 3, 10 or more VP1 nucleotide differences from the respective poliovirus; for poliovirus type 2, six or more VP1 nucleotide differences from
Sabin type 2 poliovirus.
†† Results reported within 14 days of receipt of specimen.
§§ Results of ITD reported within 7 days of receipt of isolate.
¶¶ For percentage of poliovirus isolation results on time, percentage of ITD results within 7 days of receipt at laboratory and within 60 days of paralysis onset. Total
represents weighted mean percentage of regional performance.

obscure variation at lower administrative levels. Large popula- Summary

tions residing in hard-to-reach areas might not be accessed by What is already known about this topic?
the surveillance system, which could affect the performance
The primary means for detecting poliovirus is through
indicators and their interpretation. Finally, meeting perfor- surveillance for acute flaccid paralysis (AFP), supplemented
mance indicators does not by itself ensure strong surveillance by environmental surveillance of sewage samples.
unless field activities are well supervised, and staff members What is added by this report?
are well trained. During 2022–2023, among 28 priority countries experiencing or
at high risk for poliovirus transmission, 20 (71.4%) met national
Implications for Public Health Practice AFP surveillance indicator targets, and the number of environ-
High-quality surveillance is crucial for the timely detection mental surveillance sites in priority countries increased.
of circulating polioviruses and the rapid activation of outbreak However, substantial national and subnational AFP surveillance
response vaccination activities to stop transmission. Countries gaps persist.
must monitor surveillance indicators to identify gaps and What are the implications for public health practice?
enhance the sensitivity and timeliness of surveillance activities Maintaining high-quality surveillance is critical to achieving
through supportive supervision and training to guide progress the goal of global polio eradication. Monitoring surveillance
indicators is important to identifying gaps and guiding
toward the goal of global polio eradication.
surveillance strengthening activities, particularly in countries
at high risk for poliovirus circulation.

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 Morbidity and Mortality Weekly Report

Acknowledgments References
Nina D. Dutton, Geospatial Research, Analysis and Services 1. Lee SE, Greene SA, Burns CC, Tallis G, Wassilak SGF, Bolu O. Progress
Program; The Global Polio Eradication Initiative (GPEI); Global toward poliomyelitis eradication—worldwide, January 2021–March 2023.
MMWR Morb Mortal Wkly Rep 2023;72:517–22. PMID:37167156
Polio Laboratory Network; Data and Information Management https://doi.org/10.15585/mmwr.mm7219a3
Network; Polio and Picornavirus Laboratory Branch, Division of 2. Bjork A, Akbar IE, Chaudhury S, et al. Progress toward poliomyelitis
Viral Diseases, National Center for Immunization and Respiratory eradication—Afghanistan, January 2022–June 2023. MMWR Morb
Diseases, CDC; GPEI surveillance group members. Mortal Wkly Rep 2023;72:1020–6. PMID:37733636 https://doi.
org/10.15585/mmwr.mm7238a1
Corresponding author: Nishant Kishore; [email protected]. 3. Mbaeyi C, Baig S, Safdar RM, et al. Progress toward poliomyelitis
1Global Immunization Division, Center for Global Health, CDC; 2World eradication—Pakistan, January 2022–June 2023. MMWR Morb Mortal
Health Organization, Geneva, Switzerland; 3Division of Viral Diseases, National Wkly Rep 2023;72:880–5. PMID:37590173 https://doi.org/10.15585/
Center for Immunization and Respiratory Diseases, CDC; 4World Health mmwr.mm7233a1
Organization Regional Office for the Western Pacific, Manila, Philippines; 4. Global Polio Eradication Initiative. Malawi. Geneva, Switzerland: Global
5World Health Organization Regional Office for Africa, Brazzaville, Republic Polio Eradication Initiative; 2023. https://polioeradication.org/where-
of the Congo; 6World Health Organization Regional Office for South-East we-work/malawi/
Asia, New Delhi, India.; 7World Health Organization Regional Office for the 5. Global Polio Eradication Initiative. Mozambique. Geneva, Switzerland:
Eastern Mediterranean, Amman, Jordan. Global Polio Eradication Initiative; 2023. https://polioeradication.org/
where-we-work/Mozambique/
All authors have completed and submitted the International 6. Bigouette JP, Henderson E, Traoré MA, et al. Update on vaccine-derived
Committee of Medical Journal Editors form for disclosure of potential poliovirus outbreaks—worldwide, January 2021–December 2022.
conflicts of interest. No potential conflicts of interest were disclosed. MMWR Morb Mortal Wkly Rep 2023;72:366–71. PMID:37022974
https://doi.org/10.15585/mmwr.mm7214a3
7. Wilkinson AL, Diop OM, Jorba J, Gardner T, Snider CJ, Ahmed J.
Surveillance to track progress toward polio eradication—worldwide,
2020–2021. MMWR Morb Mortal Wkly Rep 2022;71:538–44.
PMID:35421079 https://doi.org/10.15585/mmwr.mm7115a2
8. Stehling-Ariza T, Wilkinson AL, Diop OM, et al. Surveillance to track
progress toward poliomyelitis eradication—worldwide, 2021–2022.
MMWR Morb Mortal Wkly Rep 2023;72:613–20. PMID:37289657
https://doi.org/10.15585/mmwr.mm7223a1
9. Diop OM, Kew OM, de Gourville EM, Pallansch MA. The Global
Polio Laboratory Network as a platform for the viral vaccine-
preventable and emerging diseases laboratory networks. J Infect
Dis 2017;216(Suppl_1):S299–307. PMID:28838192 https://doi.
org/10.1093/infdis/jix092

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 Morbidity and Mortality Weekly Report

Federal Retail Pharmacy Program Contributions to Bivalent mRNA COVID-19

Vaccinations Across Sociodemographic Characteristics — United States,
September 1, 2022–September 30, 2023
Roua El Kalach, PharmD1; Nkenge Jones-Jack, PhD1; Mattie A. Elam, PharmD2; Abdulhakeem Olorukooba, MD1; Marley Vazquez, MPH1;
Shannon Stokley, DrPH1; Sarah Meyer, MD1; Sunanda McGarvey3; Kimvy Nguyen3; Lynn Gibbs Scharf, MPH1; LaTreace Q. Harris, MPH1;
Christopher Duggar, MPH1; Lori B. Moore, PharmD1

Abstract played during the COVID-19 response is important for

The Federal Retail Pharmacy Program (FRPP) facilitated future public health planning. The Federal Retail Pharmacy
integration of pharmacies as partners in national efforts to Program (FRPP), a collaboration between the federal govern-
scale up vaccination capacity during the COVID-19 pandemic ment, U.S. states and territories, and 21 national pharmacy
emergency response. To evaluate FRPP’s contribution chains and independent pharmacy networks, was established
to vaccination efforts across various sociodemographic to ensure broad access to COVID-19 vaccines (2). Since
groups, data on COVID-19 bivalent mRNA vaccine doses February 11, 2021, participating pharmacies have provided
administered during September 1, 2022–September 30, access to COVID-19 vaccines across all 50 states, the District
2023, were evaluated from two sources: 1) FRPP data of Columbia (D.C.), U.S. territories, and freely associated
reported directly to CDC and 2) jurisdictional immunization states (2). On September 1, 2022, CDC recommended
information systems data reported to CDC from all 50 states, COVID-19 bivalent boosters for persons aged ≥12 years (3).
the District of Columbia, U.S. territories, and freely associated On October 12, 2022, the recommendation was expanded to
states. Among 59.8 million COVID-19 bivalent vaccine include children aged 5–11 years, and on December 9, 2022,
doses administered in the United States during this period, children aged 6 months–4 years (3). COVID-19 mRNA
40.5 million (67.7%) were administered by FRPP partners. bivalent vaccine doses reported to CDC by FRPP partners and
The proportion of COVID-19 bivalent doses administered all bivalent vaccine doses administered in the United States
by FRPP partners ranged from 5.9% among children aged during September 1, 2022–September 30, 2023, were assessed
6 months–4 years to 70.6% among adults aged 18–49 years. across sociodemographic groups to learn more about FRPP’s
Among some racial and ethnic minority groups (e.g., Hispanic contribution to COVID-19 bivalent vaccination.
or Latino, non-Hispanic Black or African American, non-
Hispanic Native Hawaiian or other Pacific Islander, and Methods
non-Hispanic Asian persons), ≥45% of COVID-19 bivalent The proportion of COVID-19 bivalent vaccine doses admin-
vaccine doses were administered by FRPP partners. Further, istered in the United States by FRPP partners was calculated
in urban and rural areas, FRPP partners administered 81.6% using two independent data sources: 1) FRPP bivalent dose
and 60.0% of bivalent vaccine doses, respectively. The FRPP administration data reported directly to CDC and 2) all-
partnership administered approximately two thirds of all provider (i.e., FRPP and non-FRPP vaccine providers) data on
bivalent COVID-19 vaccine doses in the United States and bivalent vaccine dose administration submitted to each juris-
provided vaccine access for persons across a wide range of diction’s immunization information system,* which were then
sociodemographic groups, demonstrating that this program
* Providers were required by CDC to document COVID-19 vaccination in their
could serve as a model to address vaccination services needs medical records within 24 hours of administration and in their jurisdiction’s
for routine vaccines and to provide health services in other immunization information system (IIS) within 72 hours of administration
public health emergencies. during the public health emergency. IISs are confidential, computerized,
population-based systems that collect and consolidate vaccination data from
providers in 64 public health jurisdictions and can be used to track vaccines
Introduction administered across multiple provider types and measure vaccination coverage.
The 64 jurisdictions comprise the 50 U.S. States, eight U.S. territories and
Approximately 90% of U.S. residents live within 5 miles freely associated states (i.e., American Samoa, Northern Mariana Islands,
(8 km) of a community pharmacy, making pharmacies a highly Federated States of Micronesia, Guam, Marshall Islands, Palau, Puerto Rico,
accessible health care resource, particularly among low-income and the U.S. Virgin Islands), and six local jurisdictions (Chicago, Illinois;
Houston, Texas; New York, New York; Philadelphia, Pennsylvania; San Antonio,
communities (1). Understanding the role that pharmacies Texas; and Washington, D.C.).

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 Morbidity and Mortality Weekly Report

submitted to CDC by each jurisdiction,†,§ for doses admin- aged 18–49 years (70.6%), and the lowest was to children aged
istered from September 1, 2022 (the date CDC first issued 6 months–4 years (5.9%) (Table 1). More than two thirds of
the recommendation for COVID-19 bivalent vaccination for males (66.9%) and females (68.6%) were vaccinated through
persons aged ≥12 years) (3), through September 30, 2023. Data FRPP partners. By racial and ethnic group, the highest pro-
were analyzed across six age cohorts (6 months–4 years, and portions of bivalent COVID-19 doses administered by FRPP
5–11, 12–17, 18–49, 50–64, and ≥65 years), sex, seven catego- partners were among Asian (60.2%) and White persons
ries of race and ethnicity (Hispanic or Latino, non-Hispanic (56.2%), and the lowest proportions were among AI/AN
American Indian or Alaska Native [AI/AN], non-Hispanic persons (21.9%) and persons of other races (22.3%). The
Asian [Asian], non-Hispanic Black or African American, percentage of doses administered to persons with unknown
non-Hispanic Native Hawaiian or other Pacific Islander, non- race and ethnicity was higher in the FRPP data (29.4%) than
Hispanic other [other], and non-Hispanic White [White]), in the all-provider data (10.9%).
and urban-rural classification,¶,** based on the county where Among the full analytic sample of 59 distinct jurisdictions,
the vaccine dose was administered. Data were analyzed using all but five (American Samoa, Northern Mariana Islands,
Microsoft SQL Server Management Studio (version 18; Federated States of Micronesia, Marshall Islands, and Palau)
Microsoft) and are descriptive in nature. This activity was had FRPP partners. Among the 54 jurisdictions with FRPP
reviewed by CDC, deemed not research, and was conducted partners, at least one half of bivalent COVID-19 vaccine doses
consistent with applicable federal law and CDC policy.†† were administered by FRPP partners in 42 (77.8%) jurisdic-
tions. Among the 52 jurisdictions with urban designated
Results areas and the 48 jurisdictions with rural designated areas, the
Approximately 59.8 million bivalent COVID-19 doses
TABLE 1. Percentage of COVID-19 bivalent vaccinations administered
were administered in the United States during September 1, by Federal Retail Pharmacy Program partners and recipient sex, age
2022–September 30, 2023, including 40.5 million (67.7%) group, and race and ethnicity — United States, September 1, 2022–
doses administered by FRPP partners. A total of 694 records September 30, 2023
were excluded from the FRPP database and 113 from the all- No. of bivalent vaccine No. of bivalent vaccine
provider database because age data were invalid. doses administered doses administered
Characteristic by all providers by FRPP partners (%)
By age group, the highest percentage of COVID-19 biva-
Total bivalent doses* 59,776,140 40,458,857 (67.7)
lent doses administered by FRPP partners was to persons Sex†
Female 32,608,792 22,377,327 (68.6)
† Although there are a total of 64 IIS jurisdictions, the analytic sample for this Male 27,010,446 18,071,154 (66.9)
report only includes 59 distinct jurisdictions because of local jurisdictional Age group
data (i.e., Chicago, Houston, New York City, Philadelphia, and San Antonio) 6 mos–4 yrs 600,238 35,114 (5.9)
being included within their respective state’s data. 5–11 yrs 1,752,601 588,776 (33.6)
§ Bivalent vaccine dose administration data from Idaho and Texas (from persons 12–17 yrs 2,141,050 1,158,364 (54.1)
aged<18 years) were not reported to CDC through their IISs; instead, these 18–49 yrs 15,791,006 11,144,137 (70.6)
jurisdictions submitted their data on bivalent vaccine doses administered using 50–64 yrs 13,765,721 9,709,461 (70.5)
aggregate table shells aligned with the all-provider data for inclusion in the ≥65 yrs 25,725,524 17,823,005 (69.3)
overall data. Race and ethnicity§,¶
¶ The 2013 National Center for Health Statistics (NCHS) urban-rural
AI/AN 459,135 100,393 (21.9)
classification scheme (https://www.cdc.gov/nchs/data_access/urban_rural. Asian 4,481,430 2,697,529 (60.2)
htm) was used to classify counties where bivalent COVID-19 vaccine doses Black or 4,198,748 1,946,903 (46.4)
were administered in urban and rural categories. Urban counties were defined African American
by combining four of these six categories (large central metropolitan, large NH/OPI 134,374 74,571 (55.5)
fringe metropolitan, medium metropolitan, and small metropolitan), and White 35,294,990 19,826,869 (56.2)
rural counties were defined based on two categories (micropolitan and Hispanic or Latino 5,874,775 3,267,637 (55.6)
noncore). Records with missing administration counties and those lacking Other race, NH 2,836,832 632,645 (22.3)
NCHS designations were excluded from the urban-rural analyses.
** The overall analytic sample for this analysis was 59 jurisdictions; however, Abbreviations: AI/AN = American Indian or Alaska Native; FRPP = Federal Retail
Pharmacy Program; NH = non-Hispanic; NH/OPI = Native Hawaiian or other
seven U.S. territories and freely associated states (i.e., American Samoa,
Pacific Islander.
Northern Mariana Islands, Federated States of Micronesia, Guam, Marshall * A total of 694 records in the FRPP database and 113 in the all-provider database
Islands, Palau, and the U.S. Virgin Islands) lacked urban-rural county level were excluded because of invalid age.
designations. Among the remaining jurisdictions, all 52 contained urban- † The sex of the recipient was unknown for 10,376 (0.03%) bivalent vaccine dose
designated areas; however, four jurisdictions (D.C., Delaware, New Jersey, recipients reported in the FRPP data and 156,902 (0.26%) recipients reported
and Rhode Island) had no rural designations, leaving only 48 jurisdictions in the all-provider data.
represented in the final rural analyses. § The race and ethnicity of the recipient was unknown for 11,912,310 (29.4%)
†† 45 C.F.R. part 46.102(l)(2); 21 C.F.R. part 56; 42 U.S.C. Sect. 241(d);
FRPP dose recipients and 6,495,856 (10.9%) of all-provider dose recipients.
5 U.S.C. Sect. 552a; 44 U.S.C. Sect. 3501 et seq. ¶ Persons of Hispanic or Latino (Hispanic) origin might be of any race but are
categorized as Hispanic; all racial groups are non-Hispanic.

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 Morbidity and Mortality Weekly Report

proportion of bivalent doses administered by FRPP partners TABLE 2. Percentage of COVID-19 bivalent vaccine doses administered
was higher among urban areas (81.6%) compared with rural by Federal Retail Pharmacy Program partners in urban and rural
settings — United States, September 1, 2022–September 30, 2023
areas (60.0%) (Table 2). FRPP pharmacies administered
No. of bivalent vaccine
≥50% of bivalent doses in 45 of 52 (86.5%) jurisdictions’ No. of bivalent doses administered by
urban designated counties and 33 of 48 (68.8%) jurisdictions’ vaccine doses FRPP partners within
administered by geographic
rural designated counties. NCHS designation* all providers designations (%)
Total bivalent doses 59,776,140 40,458,857 (67.7)
Discussion administered†
During September 1, 2022–September 30, 2023, FRPP Records excluded§,¶ 8,943,617 64,371
Total analytic sample 50,832,523 40,394,486 (79.5)
partners administered 40.5 million bivalent COVID-19 doses, Administration setting
representing more than two thirds (67.7%) of all bivalent Urban 45,848,867 37,404,942 (81.6)
COVID-19 doses administered across the United States and its Rural 4,983,656 2,989,544 (60.0)
territories and freely associated states. In comparison, previous Abbreviations: FRPP = Federal Retail Pharmacy Program; NCHS = National
Center for Health Statistics.
data show that FRPP partners administered 45% of monova- * The 2013 NCHS urban-rural classification scheme (https://www.cdc.gov/nchs/
lent doses during February 11, 2021–January 31, 2022 (2). data_access/urban_rural.htm) was used to classify counties where bivalent
doses were administered into urban and rural categories. Urban counties were
Factors that might have contributed to the higher proportion defined by combining four of these six categories (large central metropolitan,
of bivalent compared with monovalent COVID-19 vaccines large fringe metropolitan, medium metropolitan, and small metropolitan),
doses administered by FRPP partners include a higher level and rural counties were defined based on two categories (micropolitan
and noncore).
of awareness of COVID-19 vaccine availability at pharmacies, † A total of 694 records in the FRPP data and 113 records reported in the all-

ease of accessibility (e.g., extended hours of operation, walk-in provider data were excluded because of invalid reported age.
§ A total of 0.2% of records in FRPP data, and 15% of all-provider data were
and scheduled appointments, and geographically convenient excluded because of missing county or no NCHS designation.
locations), and fewer COVID-19 mass vaccination clinics ¶ Although the overall analytic sample for this analysis was 59 jurisdictions,
seven U.S. territories and freely associated states (i.e., American Samoa,
during this period compared with the time when the original Northern Mariana Islands, Federated States of Micronesia, Guam, the Marshall
monovalent vaccine first became available (2). Although FRPP Islands, Palau, and the U.S. Virgin Islands) lacked urban-rural county-level
designations. Among the remaining jurisdictions, all 52 contained urban
partners were effective in making COVID-19 vaccines widely designated areas; however, four jurisdictions (Delaware, District of Columbia,
accessible, differences in use of FRPP partner vaccination ser- New Jersey, and Rhode Island) had no rural designations, leaving only
vices was observed across age groups, racial and ethnic groups, 48 jurisdictions represented in the final rural analyses.

sex, and urbanicity.

Despite the availability of COVID-19 vaccines through FRPP vaccinations were reported for all evaluated demo-
FRPP partners and from other vaccine providers, overall U.S. graphic groups, including all age groups. However, FRPP part-
bivalent vaccination coverage was substantially lower than that ners administered the highest proportion of bivalent vaccine
of completed monovalent primary COVID-19 vaccination doses to adults, with similar percentages of doses administered
series. Data from CDC’s COVID Data Tracker reveal that to adults in all age groups (range = 69.3%–70.6%). FRPP
as of May 11, 2023 (the end date of the public health emer- partners administered a lower proportion of bivalent doses
gency), 17% of the U.S. population had received the bivalent to children aged 5–11 years (33.6%) and 6 months–4 years
vaccine,§§ compared with 69.5% who had completed a pri- (5.9%). This difference in percentages of doses administered
mary series. Among persons considering bivalent vaccination, to adult and pediatric recipients is not unexpected: histori-
commonly reported barriers to receipt of bivalent COVID-19 cally, more adults than children have received annual influenza
vaccine have included being too busy or forgetting to get vac- vaccination at pharmacies (5). Surveys conducted during
cinated and having concerns related to side effects, whereas September 2021 found that parents reported a higher level of
the main concerns reported by persons reporting no intent trust when vaccinating their child at their regular clinic (63%),
to receive a bivalent vaccine were more often related to trust, compared with vaccination at 1) a local pharmacy (34%), 2) a
belief that vaccination was not necessary, and concerns about clinic different from their regular one (30%), 3) school with
safety. However, the results of surveys conducted in March and the parent present (25%), 4) temporary mass vaccination
April 2023 indicate that fewer than 5% of respondents reported clinic (25%), and 5) school without the parent present (15%)
access issues of time or costs as concerns, suggesting that access (6). Pharmacy administration of COVID-19 vaccination to
was not a substantial contributor to low vaccination rates (4). children was possible in part because of the Public Readiness
and Preparedness Act, which lowered the age at which children
§§ https://covid.cdc.gov/covid-data-tracker/#vaccinations_ could be vaccinated at pharmacies to 3 years in all states, mak-
vacc-total-admin-rate-total ing COVID-19 vaccination accessible for some age groups not

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 Morbidity and Mortality Weekly Report

all-provider data, which included vaccinations administered

Summary
to children and infants as young as age 6 months. Third,
What is already known about this topic?
the higher number and percentage of records with race and
Pharmacies participating in the Federal Retail Pharmacy ethnicity reported as unknown in the FRPP data compared
Program (FRPP) served as integral partners in national efforts to
scale up vaccination capacity during the COVID-19 pandemic
with those in the all-provider data might have resulted in
emergency response. less accurate representation and potential underestimation
What is added by this report?
of FRPP contributions for some racial and ethnic groups.
Finally, the National Center for Health Statistics Urban-Rural
Among 59.8 million COVID-19 bivalent vaccine doses administered
in the United States during September 1, 2022–September 30, Classification was developed in 2013, and the urban-rural
2023, 40.5 million (67.7%) were administered by FRPP partners. designations used likely affected these analyses. Several coun-
In urban and rural areas, FRPP partners administered 81.6% and ties classified as rural in 2013 might no longer be rural. In
60.0% of bivalent vaccine doses, respectively. addition, a larger percentage of records were removed from the
What are the implications for public health practice? all-provider data (15.0%) than from the FRPP data (0.2%)
FRPP partnerships were critical in ensuring access to bivalent because of the lack of matching urban–rural classification. Both
COVID-19 vaccination services in the United States and could factors might have skewed the overall pharmacy contribution,
serve as a model to address vaccination services needs for particularly in examining the percentage of urban and rural
routine vaccines and during future responses to vaccine-pre-
doses administered by FRPP partners.
ventable disease emergencies.
Implications for Public Health Practice
typically vaccinated at pharmacies in many states (7). Although FRPP partners were critical in ensuring access to bivalent
FRPP helped during this public health emergency, pediatri- COVID-19 vaccination services throughout the United States.
cians, health departments and federally qualified health centers This partnership could serve as a model to address vaccination
were needed to ensure that young children had adequate access services needs for administration of routinely recommended
to COVID-19 vaccines. vaccines and potential future responses to vaccine-preventable
FRPPs administered a large proportion of COVID-19 disease emergencies. Further strategies to support improvement
bivalent doses to most racial and ethnic groups. However, the in race and ethnicity data collection and reporting, particularly
proportion was lower for AI/AN persons, a group that might in pharmacy settings, are needed to help guide public health
have relied more on Indian Health Service facilities or other practices. Although the public health emergency has ended,
vaccine providers. the need to ensure that the U.S. population has equitable
The FRPPs’ contribution to COVID-19 bivalent doses was access to all recommended vaccines, including COVID-19
higher among urban than rural counties. Possible reasons for vaccines, remains. FRPP demonstrated that partnering with
this difference are the potential higher accessibility of pharma- pharmacies, in addition to other vaccine providers, can help
cies in urban areas, as well as the fact that independent pharma- accelerate vaccine access provision across the United States
cies in rural areas might have been less likely to partner with the and address other potential infectious diseases-related public
FRPP. In addition, factors such as the availability of bivalent health emergencies.
COVID-19 vaccines in primary care settings or other settings
could have affected the proportion of COVID-19 bivalent Acknowledgments
doses administered by FRPP partners located in urban versus The 21 pharmacy partners participating in the Federal Retail
rural areas (8,9). Further evaluations are needed to understand Pharmacy Program, federal entities, immunization program
the factors contributing to differences in pharmacy provider managers; immunization information system managers; other staff
vaccination among urban and rural residents. members of the immunization programs in the 64 jurisdictions that
submitted COVID-19 data to CDC; CDC COVID-19 Vaccine
Limitations Task Force.
The findings in this report are subject to at least four limita- Corresponding author: Roua El Kalach, [email protected].
tions. First, COVID-19 vaccination coverage estimates were 1Immunization Services Division, National Center for Immunization and
not possible using data from this analysis because unique per- Respiratory Diseases, CDC; 2Goldbelt Professional Services, LLC, Chesapeake,
sons vaccinated could not be identified. Second, the age groups Virginia; 3Peraton, Reston, Virginia.
used to describe COVID-19 vaccination among younger All authors have completed and submitted the International
children include those aged 6 months–4 years. However, FRPP Committee of Medical Journal Editors form for disclosure of potential
data only include vaccinated children aged ≥3 years, unlike the conflicts of interest. No potential conflicts of interest were disclosed.

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 Morbidity and Mortality Weekly Report

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ability and interest in administering COVID-19 vaccines in the Southern
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 Morbidity and Mortality Weekly Report

Notice to Readers

Change in Publication Date of QuickStats

Effective this issue, MMWR will publish QuickStats on a
bimonthly basis, in the first and third issues of each month.
QuickStats will continue to present concise data from CDC’s
National Center for Health Statistics on a wide range of timely
and important health topics. To supplement QuickStats, a
detailed table will be posted in CDC Stacks and linked to
each QuickStats.

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 Morbidity and Mortality Weekly Report

Erratum

Vol. 71, No. 19

In the report, “Notes from the Field: Trends in Gabapentin
Detection and Involvement in Drug Overdose Deaths —
23 States and the District of Columbia, 2019–2020,” on
page 664, in the fifth paragraph, the first sentence should have
read, “The percentage of deaths with gabapentin detected
that were opioid-involved remained consistently high, ranging
from 85% to 90%.”

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 Morbidity and Mortality Weekly Report

QuickStats

FROM THE NATIONAL CENTER FOR HEALTH STATISTICS

Life Expectancy at Birth, by Sex — United States, 2019–2022

84

82

80
Life expectancy, yrs

78

76

74

72

70 Total Male Female

0
2019 2020 2021 2022
Year

Life expectancy at birth for the U.S. population in 2022 was 77.5 years, an increase from 76.4 years in 2021. Although life
expectancy rose in 2022 for the first time since the COVID-19 pandemic began, it remains lower compared with prepandemic
life expectancy in 2019 (78.8 years). This pattern was similar for males and females.
Supplementary Table: https://stacks.cdc.gov/view/cdc/151563
Sources: National Vital Statistics System, United States Life Tables, 2021 (https://www.cdc.gov/nchs/data/nvsr/nvsr72/nvsr72-12.pdf ); Mortality
in the United States, 2022 (https://www.cdc.gov/nchs/products/databriefs/db492.htm).
Reported by: Arialdi M. Miniño, MPH, [email protected]; Jiaquan Xu, MD.

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 Morbidity and Mortality Weekly Report

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